A fundamental ethical principle in surgery is that a patient's voluntary consent is obtained prior to any invasive procedure. This can be verbal or written but it demands that the patient has received prior, sufficient, appropriate information to be able to make a reasoned judgement on what is being offered to them. As I indicated in the section on surgical outcome there is a partnership between the patient and the healthcare professionals to reduce any potential risks and to strive to achieve a satisfactory outcome to all. Clearly this means that the individual patient must receive adequate information and it is my practice to routinely do this. Nevertheless some patients require more information than others and hopefully this section will help in providing the extra.
Risks and complications can be considered in a number of different ways but I propose to look at them simply from the aspect of the general complications that can occur with any surgical procedure and anaesthetic and then the more specific local risks of hand surgery itself.
I do not propose to go into detail concerning anaesthesia. There are many useful sources of information available to patients. I recommend the following patient information leaflet from The Association of Anaesthetists of Great Britain and Ireland in conjunction with The Royal College of Anaesthetists. An additional leaflet gives more information. You will need Adobe Reader to view these files. If you do not have this installed on your computer and wish to, then follow this
In my opinion hand and wrist surgery lends itself to regional and local anaesthesia. This technique is now used for at least 85% of my patients. It is not for everyone and if the thought of being awake during the surgical procedure is too much for a patient, then it is perfectly reasonable to opt for a general anaesthetic. However, because of the short nature of some operations, e.g. less than 10 minutes for the operation, then a local or regional seems more appropriate.
Smoking delays healing, perhaps not so obviously in skin healing but certainly when bone is involved. The outcome of an operation that involves bone grafting is significantly reduced when the patient is a smoker. My own surgical practice experience on operating on smokers confirms this fact and it is well publicised in the literature (please review the following links: What you need to know about orthopaedics and Hughston Health Alert). There is a debate in the surgical world as to whether surgeons should operate on smokers when the outcome is so affected. Personally I have not refused to do an operation on a smoker but it does mean that the patient has take on much greater responsibility if the operation outcome is poor.
Infection - any invasive procedure carries a risk of infection. Fortunately in the hand this risk is very low indeed as the hand has such an excellent blood supply. If infection does occur it is usually treated easily with antibiotics.
Wound breakdown - this complication is again rare mainly due to the excellent blood supply to the hand, though it is higher in some general medical conditions as already mentioned.
Nerve damage - The aim of all surgery is to minimise the risk of damage to local structures as much as possible. For the vast majority of operations performed in the hand and wrist the risk of nerve damage is extremely low but there are certain, specific operations where the risk is higher, these include fasciectomy, dermofasciectomy and excision of odd lumps in the finger.
Vascular damage - The risk of damage to a critical artery is very rare indeed but two procedures spring to mind where the risk is much higher. As already stated there is a higher risk in dermofasciectomy. The other procedure is excision of a volar ganglion where the latter can be stuck onto the radial artery. I am well aware of this risk so I take particularly care to make sure I preserve the artery.
Stiffness - A key element to normal function is the natural flexibility of the fingers which we take for granted. There are a number of conditions affecting the hand and wrist which can cause stiffness in their own right but unfortunately a specific complication of surgery in the hand is stiffness. It is critical, therefore that you follow the relevant post-operative instructions concernng exercises to try and reduce this risk. Stiffness is a particular problem in finger joint arthritis, certain types of wrist surgery and Dupuytren's contractures.
Complex Regional Pain Syndrome - this condition is covered in detail in the complications associated with dermofasciectomy.